OPHTHA L MO LO G Y

CASE PRESE N TA TIO N

JOHN CHRISTOPHER L. LUCES
CLINICAL CLERK
WVSU-COM
GENERAL DATA
PATIENT: M. M.
56 YEARS OLD
FEMALE/ MARRIED
BOLILAO, MANDURRIAO, ILOILO COTY
CHIEF COMPLAINT

BLURRING OF VISION
OD<OS
HISTORY
HPI
3 MO PTC:
Patient started experiencing ear itchiness
accompanied by blurry of vision on the left eye
Occasional frontal headache was also
experienced by the patient
2 MO PTC:
Same symptoms persisted
Patient also experienced blurring of vision on her right
eye
She went back to the optometrist and there she was
given new set of glasses
HPI
FEW DAYS PTC:
Same symptoms persisted thus decided
to sought consult in this instituion
 PAST MEDICAL HISTORY
Hypertension (2015)- Amlodipine 10mg/tab OD
DM (2016)- Metformin 5 mg/tab OD
Gallstones

ears ago: Nearsightedness

FAMILY HISTORY
(+) HYPERTENSION: father side
(+) DM: mother side
(+) OCULAR PROBLEM
(unrecalled)- father
PERSONAL-SOCIAL HISTORY
Patient is a dressmaker
She is a non-alcoholic beverage drinker
and non-smoker
PHY SI C A L E X A M IN ATI ON
GENERAL SURVEY
AWAKE
AMBULATORY
NOT IN CARDIOPULMONARY DISTRESS
GCS 15 (E4V5M6)
RESPONSIVE, COHERENT, CONVERSANT
ORIENTED TO TIME, PLACE AND PERSON.
VITAL SIGNS
Normal Values
Temperature 37.1C 36.5-37.5C
Cardiac Rate 89 bpm 60-100 bpm
Respiratory Rate 18 cpm 12-20 cpm
SBP<120mmHg;
Blood Pressure 120/80 mmHg
DBP <80 mmHg
PHYSICAL EXAMINATION

HEENT AS, PC, PERRLA, NNVE, NCLAD

CHEST SCE, CBS, AP, NCRRR, (-) murmurs
ABDOMEN Soft, non-tender abdomen
EXTREMITIES Grossly Normal Extremities
OPHTHA L M OL OG IC
EXA M IN AT I O N
GROSS EYE EXAMINATION

NO ACTIVE LESIONS ON THE OCULAR ADNEXA

PINK CONJUNCTIVA, WHITE SCLERA
NO APPARENT OPACITY
(-) SWELLING, ERYTHEMA, TENDERNESS OR MASS
PUPILLARY EXAMINATION

OD: 3 mm, BRTL, (+) direct &

consensual PR
OS: 3 mm, BRTL, (+) direct &
consensual PR
MOTILITY EXAM

Able to move the eye freely in 6 Able to move the eye freely in 6 cardinal
cardinal gazes gazes
FUNDOSCOPIC EXAMINATION

OD OS

(+) ROR (-) ROR

Fundoscopy
Slightly Hazy media Hazy media
VISUAL ACUITY
EYE EXAM OD OS

Visual Acuity 20/200 -2 CF- 4ft

Pin hole: 20/80

TONOMETRY
EYE EXAM OD OS

Tonometry 16 16
SLIT LAMP BIOMICROSCOPY

OD OS
POSTERIOR SUBSCAPULAR OPACIFICATION OF LENS
 IMP R E SS ION:
SUBSCAPULAR CATARACT OU
PLANS
FOR DILATED FUNDUSCOPY
ADVISED CATARACT SURGERY BUT STILL UNDECIDED
FOR FBS
TCB ONCE DECIDED
CATARACT
ANATOMY
 ANATOMY
Biconvex, avascular, transparent
structure enclosed by a capsule

Capsule is responsible for moulding the

lens substance during accommodation;
lens capsule is pliable

Capsule is thickest at equatorial zone and

thinnest at posterior pole of lens

Lens substance consist of the nucleus,

the central compacted core surrounded
by the cortex.
CATARACT
Cataractous lenses are characterized by protein
aggregates that scatter light rays and reduce
transparency. Other protein alterations result in
yellow or brown discoloration. Additional findings
may include vesicles between lens fibers or
migration and aberrant enlargement of epithelial
cells

Cataract is an ophthalmologic diagnosis. It is

irrespective of vision as long as there is opacity.
CATARACTS

AGE-RELATED CATARACT
PRESENILE CATARACT
TRAUMATIC CATARACT
DRUG INDUCED CATARACT
SECONDARY CATARACT
AGE - R E L ATE D C ATAR A C T
AGE-RELATED CATARACT

NOT HEREDITARY
COMMON CAUSE OF PREVENTABLE BLINDNESS
MEAN AGE: 65Y.O.
CLASSIFICATION ACCORDING TO MORPHOLOGY
1. SUBCAPSULAR CATARACT
ANTERIOR SUBCAPSULAR
- LIES DIRECTLY UNDER THE LENS CAPSULE

POSTERIOR SUBCAPSULAR
- LIES JUST IN FRONT OF THE POSTERIOR CAPSULE.
MORE COMMON THAN ANTERIOR AND MORE
PROFOUND EFFECT ON VISION THAN A COMPARABLE
NUCLEAR OR CORTICAL CATARACT. NEAR VISION MORE
IMPAIRED THAN DISTANCE VISION.
 POSTERIOR SUBCAPSULAR CATARACT

AN OPACITY IN THE LENS POSITIONED JUST ANTERIOR TO THE

POSTERIOR LENS CAPSULE AND CHARACTERIZED BY THE POSTERIOR
MIGRATION OF LENS EPITHELIAL CELLS FROM THE LENS BOW.
INCIDENCE/PREVALENCE: POSTERIOR SUBCAPSULAR CATARACT MAY
BE THE MOST COMMON ABNORMALITY INVOLVING THE LENS
EPITHELIUM

THE LENS IS COMPOSED LARGELY OF CRYSTALLINS WHICH

AGGREGATE IN CATARACT FORMATION. THERE ARE MANY
ASSOCIATIONS WITH POSTERIOR SUBCAPSULAR CATARACTS
INCLUDING CHRONIC VITREAL INFLAMMATION, IONIZING RADIATION,
TRAUMA AND PROLONGED USE OF CORTICOSTEROIDS.
 POSTERIOR SUBCAPSULAR CATARACT
CLINICAL FINDINGS:

Symptoms include complaints of glare at night with bright headlights or poor vision with
accommodation.

Near vision may often be more affected than distance vision.

The earliest sign is a focal dot-like area on the posterior capsule or a reflective sheen.
With progression, translucent opacities appear (the swollen wedl cells) on the posterior
capsule that have been likened to a cloth of gold or fish eggs. Posterior capsular
cataract is associated with cortical degeneration and nuclear sclerosis.
CLASSIFICATION ACCORDING TO MORPHOLOGY

2. NUCLEAR CATARACT
- ASSOCIATED WITH MYOPIA.
MYOPIC SHIFT- NEAR VISION IS BETTER. PATIENT MAY FEEL THAT THEIR VISION IS
RESTORED.
HOWEVER, THIS IS ONLY TEMPORARY. OVERTIME, THE LENS WILL GROW AND THICKEN
SECOND SIGHT OF THE AGED
YELLOWISH EARLY AND BRUNESCENT IN LATER STAGES. HARD IN CONSISTENCY.AND THE CATARACT
WILL MATURE.
CLASSIFICATION ACCORDING TO MORPHOLOGY
3. CORTICAL CATARACT
MAY INVOLVE THE ANTERIOR, POSTERIOR, OR EQUATORIAL
CORTEX. START AS CLEFTS AND VACUOLES. TYPICAL CUNEIFORM
(WEDGE-SHAPED) OR RADIAL SPOKE LIKE OPACITIES. DOES NOT
AFFECT VISION THAT MUCH.
4. CHRISTMAS TREE CATARACT
UNCOMMON. POLYCHROMATIC (GLOWS WHEN YOU CHECK ON
SLITLAMP EXAM), NEEDLE-LIKE DEPOSITS IN THE DEEP CORTEX
AND NUCLEUS. SHAPE IS SIMILAR TO CHRISTMAS TREE.
CLASSIFICATION ACCORDING TO MATURITY

1. IMMATURE CATARACT- lens is partially opaque

2. MATURE CATARACT- lens is completely opaque
3. HYPERMATURE CATARACT- shrunken and wrinkled anterior
capsule; milky.
4. MORGAGNIAN CATARACT- a hypermature cataract in which
total liquefaction of cortex allows the nucleus to sink inferiorly
5. INDUMESCENT- if the lens takes up water.
P R E SE NIL E C ATAR A C T
PRESENILE CATARACT

MEAN AGE OF CATARACT DEVELOPMENT AT 65 Y.O.

(ACCORDING TO THE AMERICAN ACADEMY OF
OPHTHALMOLOGY AND THE PHILIPPINE BOARD OF
OPHTHALMOLOGY). PRESENCE OF SYSTEMIC DISORDERS
MAY CAUSE EARLIER ONSET OF CATARACT FORMATION
PRESENILE CATARACT

1. DIABETES MELLITUS- ASIDE FROM CATARACT, CAN AFFECT REFRACTIVE INDEX

OF LENS AND ITS AMPLITUDE OF ACCOMMODATION. CAN AFFECT REFRACTIVE
INDEX AND AFFECT, CAN AFFECT AMPLITUDE OF ACCOMMODATION. CATARACT
STARTS 50+ Y

A) CLASSICAL DIABETIC CATARACT- SORBITOL ACCUMULATES WITHIN THE LENS

SNOWFLAKE CORTICAL OPACITIES IN THE YOUNG DIABETIC.
B) AGE-RELATED CATARACT- OCCURS EARLIER IN DM PATIENTS NUCLEAR OPACITIES
ARE COMMON AND PROGRESS RAPIDLY
C) PREMATURE PRESBYOPIA- DUE TO REDUCED PLIABILITY OF LENS. EARLY LOSS
OF ACCOMMODATION OR ABILITY OF THE EYE TO ADJUST TO DISTANCE DUE TO AGING
PRESENILE CATARACT

2. MYOTONIC DYSTROPHY- VISUALLY INNOCUOUS, FINE CORTICAL. EVOLVES

INTO VISUALLY DISABLING STELLATE POSTERIOR SUBCAPSULAR. IRIDESCENT
OPACITIES IN THE 3RD DECADE AND CATARACT BY THE 5TH DECADE. DEVELOPS
SLOWLY, TAKES ABOUT 2 DECADES FOR CATARACT TO DEVELOP

3. ATOPIC DERMATITS- IN 10% OF PATIENTS WITH SEVERE DERMATITIS,

CATARACT DEVELOP. A) SHIELD-LIKEDENSE ANTERIOR SUBCAPSULAR PLAQUE B)
POSTERIOR SUBCAPSULAR

4. NEUROFIBROMATOSIS TYPE 2- POSTERIOR SUBCAPSULAR OR POSTERIOR

CORTICAL OPACITIES.
TRAUMATIC CATARACT

Trauma is the most common cause of

unilateral cataract in young individuals
secondary to physical trauma due to their
active lifestyle and risk taking behaviors.
Bilateral cataracts are not as common but are
possible depending on the extent of injury
TRAUMATIC CATARACT

1. DIRECT PENETRATING
2. CONCUSSION
3. ELECTRIC SHOCK AND LIGHTNING
4. IONIZING RADIATION
5. INFRARED RADIATION
DRUG-INDUCED CATARACT
STEROIDS- SYSTEMIC, TOPICAL, (EVEN INHALED FORM) ARE CATARACTOGENIC.
OPACITIES ARE INITIALLY POSTERIOR SUBCAPSULAR THEN LATER AFFECT
ANTERIOR SUBCAPSULAR REGION THEN LATER BECOMES MATURE CATARACT
CHLORPROMAZINE- DOSE-RELATED AND IRREVERSIBLE
BUSULPHAN- USED IN TREATMENT OF CHRONIC MYELOCYTIC LEUKEMIA, MAY
OCCASIONALLY CAUSE LENS OPACITY
AMIODARONE- IN TREATMENT OF CARDIAC ARRHYTHMIAS, CAUSES
INCONSEQUENTIAL ANTERIOR SUBCAPSULAR OPACITIES
5. GOLD- IN TREATMENT OF RHEUMATOID ARTHRITIS, INNOCUOUS ANTERIOR
CAPSULAR OPACITIES IN 50% OF PTS OF >3YRS TREATMENT
SECONDARY CATARACT

1. CHRONIC ANTERIOR UVEITIS

2. ACUTE CONGESTIVE ANGLE CLOSURE GLAUCOMA
3. HIGH (PATHOLOGIC) MYOPIA
4. HEREDITARY FUNDUS DYSTROPHY
CONGENITAL CATARACTS

1. CATARACTS WITH NO SYSTEMIC ASSOCIATION

2. CATARACTS WITH SYSTEMIC ASSOCIATION
CATARACTS WITH SYSTEMIC ASSOCIATION
PRENATAL INFECTIONS
1. CONGENITAL RUBELLA
2. TOXOPLASMOSIS
3. CMV
4. HERPES SIMPLEX
5. VARICELLA
CATARACTS WITH SYSTEMIC ASSOCIATION

CHROMOSOMAL ABNORMALITIES
1.DOWN SYNDROME
2.PATAU SYNDROME (TRISOMY 11)
3.EDWARD SYNDROME (TRISOMY 18)
 CATARACT- PATHOPHYSIOLOGY
DEVELOPMENTAL METABOLIC EXPOSURE TRAUMA

Chemicals Foreign Body

Congenital Congenital
Radiation
Senile Acquired
Drugs

OPACITY OF LENS
BLOCKING THE PATHWAY OF LIGHT TOWARDS RETINA
MANAGEMENT

INDICATIONS FOR SURGERY

VISUAL IMPROVEMENT- BY FAR THE MOST COMMON INDICATION FOR CATARACT
SURGERY. SURGERY IS INDICATED ONLY IF AND WHEN CATARACT DEVELOPS TO A
DEGREE SUFFICIENT TO CAUSEDIFFICULTY IN PERFORMING DAILY ESSENTIAL ACTIVITIES
MEDICAL INDICATIONS- IN WHICH A CATARACT IS ADVERSELY AFFECTING THE HEALTH
OF THE EYE
REMOVAL OF CATARACT
3. COSMETIC INDICATIONS RARE
CATARACT SURGERY

EXTRA-CAPSULAR CATARACT EXTRACTION (ECCE)

REQUIRES A RELATIVELY LARGE CIRCUMFERENTIAL
LIMBAL INCISION(8-10MM) THROUGH WHICH THE LENS IS
EXTRACTED AND THE CORTICAL MATERIAL ASPIRATED
INTACT POSTERIOR CAPSULE ACT AS HAMMOCK WHERE
YOU PLACE YOUR IOL
 CATARACT SURGERY
PHACOEMULSIFICATION (PHACO)
A SMALL HOLLOW NEEDLE, USUALLY TITANIUM, ATTACHED TO A
HANDPIECE CONTAINING A PIEZO-ELECTRICAL CRYSTAL, VIBRATES AT
ULTRASONIC FREQUENCIES. TIP IS APPLIED TO THE LENS NUCLEUS.
CAVITATION OCCURS AT THETIP AS NUCLEUS IS EMULSIFIED. AN
IRRIGATING OR ASPIRATION SYSTEM REMOVES THE EMULSIFIED
MATERIAL FROM THE EYE.
IOL IS INSERTED (IF FOLDED) OR INJECTED THROUGH A
MUCHSMALLER INCISION THAN ECCE.
COMPLICATIONS
1. CORNEAL EDEMA. USUALLY TRANSIENT AND DUE TO INTRAOPERATIVE TRAUMA
2. IRIS PROLAPSE LEAKING INCISION, INADEQUATE SUTURING, PATIENT COUGHING OR
STRAINING.
3. MALPOSITION OF IOL ALTHOUGH UNCOMMON, MALPOSITION MAY BE ASSOCIATED
WITH BOTH OPTICAL AND STRUCTURAL PROBLEMS. ANNOYING VISUAL ABERRATIONS
INCLUDE GLARE,HALOES, AND MONOCULAR DIPLOPIA IF THE EDGE OF THE IOL BECOMES
DISPLACED INTO THE PUPIL.
4. RETINAL DETACHMENT. LATTICE DEGERATION, RETINAL BREAKS, HIGH MYOPIA,
DISRUPTION OF POSTERIOR CAPSULE, VITREOUS LOSS
5. CYSTOID MACULAR EDEMA (CME) RUPTURE OF POSTERIOR CAPSULE OR VITREOUS
AND PROLAPSE. SYMPTOMATIC CME IS RELATIVELY UNCOMMON FOLLOWING
UNCOMPLICATED PHACOEMULSIFICATION AND IN MOST CASES IT IS MILD AND
TRANSIENT. IT OCCURS MORE OFTEN AFTER COMPLICATED SURGERY AND HAS A PEAK
INCIDENCE AT 610 WEEKS, ALTHOUGH THE INTERVAL MAY BE MUCH LONGER.